The political system in the United States divides powers between federal and state governments and among executive, legislative, and judicial branches at both levels. The presidency, part of the executive branch of the federal government, is the institution most capable of providing domestic and foreign policy leadership. The presidency, broadly defined, includes not only the person of the president himself but also the vice president, the First Lady, and other senior advisers in the executive office of the president, as well as members of the Cabinet and heads of other government departments and agencies.
Presidents frequently maintain a low profile with newly identified public health hazards. They often perceive that such concerns offer little political gain and many risks. Gerald Ford's 1976 announcement of the swine flu program was an exception. The response of Presidents Ronald Reagan and George Bush to AIDS fits the more general pattern of presidential caution in addressing public health concerns.
For Reagan, AIDS presented a number of potentially serious political risks. As a presidential candidate, Reagan promised to eliminate the role of the federal government in the limited American welfare state, as well as to raise questions of morality and family in social policy. When AIDS was first reported in 1981, Reagan had recently assumed office and had begun to address the conservative agenda by slashing social programs and cutting taxes and by embracing conservative moral principles. As a result, Reagan never mentioned AIDS publicly until 1987. Most observers contend that AIDS research and public education were not funded adequately in the early years of the epidemic, at a time when research and public education could have saved lives.
In the early 1980s, senior officials from the Department of Health and Human Services pleaded for additional funding behind the scenes while they maintained publicly, for political reasons, that they had enough resources. The Reagan administration treated AIDS as a series of state and local problems rather than as a national problem. This helped to fragment the limited governmental response early in the AIDS epidemic.
AIDS could not have struck at a worse time politically. With the election of Reagan in 1980, the "New Right" in American politics ascended. Many of those who assumed power embraced political and personal beliefs hostile to gay men and lesbians. Health officials, failing to educate about transmission and risk behavior, undermined any chance of an accurate public understanding of AIDS. The new conservatism also engendered hostility toward those with AIDS. People with AIDS (PWAs) were scapegoated and stigmatized. It was widely reported, as well, that New Right groups, such as the Moral Majority, successfully prevented funding for AIDS education programs and counseling services for PWAs. At various points in the epidemic, conservatives called for the quarantining and tattooing of PWAs. Jerry Falwell, the leader of the Moral Majority, was quoted as stating: "AIDS is the wrath of God upon homosexuals."
This larger conservative climate enabled the Reagan administration's indifference toward AIDS. The administration undercut federal efforts to confront AIDS in a meaningful way by refusing to spend the money Congress allocated for AIDS research. In the critical years of 1984 and 1985, according to his White House physician, Reagan thought of AIDS as though "it was measles and it would go away." Reagan's biographer Lou Cannon claims that the president's response to AIDS was "halting and ineffective." It took Rock Hudson's death from AIDS in 1985 to prompt Reagan to change his personal views, although members of his administration were still openly hostile to more aggressive government funding of research and public education. Six years after the onset of the epidemic, Reagan finally mentioned the word "AIDS" publicly at the Third International AIDS Conference held in Washington, D.C. Reagan's only concrete proposal at this time was widespread routine testing.
Reagan and his close political advisers also successfully prevented his surgeon general, C. Everett Koop, from discussing AIDS publicly until Reagan's second term. Congress mandates that the surgeon general's chief responsibility is to promote the health of the American people and to inform the public about the prevention of disease. In the Reagan administration, however, the surgeon general's central role was to promote the administration's conservative social agenda, especially pro-life and family issues.
At a time when the surgeon general could have played an invaluable role in public health education, Koop was prevented from even addressing AIDS publicly. Then, in February 1986, Reagan asked Koop to write a report on the AIDS epidemic. Koop had come to the attention of conservatives in the Reagan administration because of his leading role in the anti-abortion movement. Reagan administration officials fully expected Koop to embrace conservative principles in his report on AIDS.
When the Surgeon General's Report on Acquired Immune Deficiency Syndrome was released to the public on October 22, 1986, it was a call for federal action in response to AIDS, and it underscored the importance of a comprehensive AIDS education strategy, beginning in grade school. Koop advocated the widespread distribution of condoms and concluded that mandatory identification of people with HIV or any form of quarantine would be useless in addressing AIDS. As part of Koop's broad federal education strategy, the Public Health Service sent AIDS mailers to 107 million American households. Koop's actions brought him into direct conflict with William Bennett, Reagan's secretary of education. Bennett opposed Koop's recommendations and called for compulsory HIV testing of foreigners applying for immigration visas, for marriage license applicants, for all hospital patients, and for prison inmates.
The Reagan administration did little to prohibit HIV/AIDS discrimination. The administration placed responsibility for addressing AIDS discrimination issues with the states rather than with the federal government. In the face of federal inaction, some states and localities passed laws that prohibited HIV/AIDS discrimination. It took the Supreme Court, in its 1987 School Board of Nassau County, Fla. v. Arline decision, to issue a broad ruling that was widely interpreted as protecting those with HIV or AIDS from discrimination in federal executive agencies, in federally assisted programs or activities, or by businesses with federal contracts.
Reagan did appoint the Presidential Commission on the Human Immunodeficiency Virus Epidemic in the summer of 1987; it was later renamed the Watkins Commission, after its chair. With the appointment of this commission, Reagan was able to appease those who demanded a more sustained federal response to AIDS. He also answered the concerns of the New Right by appointing an AIDS commission that included few scientists who had participated in AIDS research and few physicians who had actually treated PWAs. In addition, the commission included outspoken opponents of AIDS education.
In retrospect, it is clear that the commission was created to deflect attention from the administration's own inept policy response to AIDS. The Watkins Commission's final report did recommend a more sustained federal commitment to address AIDS, but this recommendation was largely ignored by both the Reagan and Bush administrations. None of the commissions studying AIDS over the years has recommended a massive federal effort to confront AIDS at all levels of society.
As Reagan's vice president in 1987, Bush nominally headed the AIDS Executive Committee of the National Institutes of Health. Bush also had to balance his roles as Reagan's adviser with his role as a presidential candidate in the 1988 election. In doing so, Bush appealed to the New Right by endorsing policies that would publicly identify people who were HIV-positive and that required mandatory HIV tests when people applied for marriage licenses. On the 1988 presidential campaign trail, Bush argued that HIV testing is more cost-effective than spending money on treatment. After Bush was elected president in 1988, it came as no surprise that he continued most of the policies of the Reagan era. Bush did appear, however, to be more sensitive to the magnitude of the AIDS crisis.
In terms of public policy, the Bush administration continued Reagan's fiscal austerity with respect to AIDS. In addition, Bush embraced mandatory testing to prevent the spread of AIDS. Finally, his administration argued that local officials should design and implement AIDS educational strategies, although federal resources could be used to gather more AIDS information. His surgeon general, Antonia Novello, maintained a low profile on AIDS issues.
It was not until March 30, 1990, almost nine years after AIDS was first identified and over a year into his presidency, that George Bush gave his first speech on AIDS. He praised his administration's efforts in dealing with the AIDS crisis and asked the country to end discrimination against those infected with HIV. At the same time, Bush refused to eliminate a federal policy that placed restrictions on HIV-positive foreigners who wished to enter the United States. The speech was heralded as the strongest public commitment ever articulated by a president, even though most AIDS activists argued that it was the kind of speech that should have been given in the early 1980s. Bush was criticized for not endorsing a comprehensive federal policy for addressing AIDS and for perpetuating discrimination against HIV-positive individuals who wished to enter the United States. However, Bush did sign the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act into law in 1990, although he consistently opposed funding this legislation to the degree its congressional supporters requested. The legislation was originally designed to provide federal assistance for urban areas that were hardest hit by AIDS.
The election of Bill Clinton and Al Gore to the White House in 1992 created hope that a new administration would offer a sustained and comprehensive federal effort to address AIDS on the magnitude of a Manhattan Project (which produced the first nuclear weapons in the 1940s). Clinton had campaigned actively for gay and lesbian support and had ensured that Bob Hattoy, an openly gay man who had been diagnosed with AIDS, would address the Democratic National Convention in New York in the summer of 1992. Clinton promised that if elected, he would appoint a national AIDS policy director, or "AIDS czar," to coordinate AIDS policy from the White House, and that he would commit more funding to AIDS research and education than had his Republican predecessors. In addition, he ridiculed the Bush administration's retrograde policy banning the immigration of HIV-positive foreigners to the United States.
AIDS activists and PWAs were soon disappointed. Although Clinton discussed AIDS more often than had his predecessors, he failed to propose the kind of comprehensive plan that activists had expected. The Clinton administration argued that only so much could be done, given the deficit they had inherited from the Reagan and Bush administrations. Soon after taking office, Clinton decided not to challenge Congress when it voted to reinforce the Bush policy of preventing HIV-positive foreigners from entering the United States.
It also took the Clinton administration considerable time to settle on an AIDS czar; after much delay, the choice was Kristine Gebbie, a nurse and Washington state health official without extensive policy-making experience. Gebbie departed about a year later in the wake of criticism by AIDS groups. She was replaced by Patricia Fleming, who had served on the staff of former U.S. Representative Ted Weiss of New York, advising him on AIDS issues. Fleming was succeeded in 1997 by Sandy Thurman, the former executive director of an AIDS service organization in Atlanta, Georgia.
Another high-profile Clinton appointee was Arkansas physician and pediatrics professor Joycelyn Elders as surgeon general. Elders's outspoken endorsement of sex education and AIDS-prevention outreach earned her many admirers among AIDS activists and many opponents among conservatives, who derisively dubbed her the "Condom Queen." Following Republican victories in the 1994 congressional elections, Clinton forced Elders's resignation when she angered conservatives by appearing to call for the teaching of masturbation to schoolchildren; in fact, Elders had simply endorsed comprehensive sex education programs.
Clinton again disappointed his supporters in the AIDS activist community when he failed to endorse a promised needle-exchange program to target injecting drug users. Adopting a cautious middle ground, the administration called for a federally funded study on needle exchange and concluded that more research was needed before any needle-exchange policy could be proposed. In addition, in the face of conservative criticism, the Clinton administration eliminated mandatory AIDS education programs for federal workers, much to the dismay of AIDS activists.
In February 1996, President Clinton agreed to sign a defense authorization bill that included a proposal to discharge all HIV-positive personnel from the military. As signed into law, the proposal would have discharged over 1,000 healthy, asymptomatic people with HIV from the military. Clinton issued a public statement that he recognized this provision as both abhorrent and unconstitutional, but that he had to support the full defense authorization measure. He promised that his attorney general would not defend the new policy in court when its constitutionality was challenged. That provision of the law was ultimately rescinded by Congress.
For those concerned about AIDS as a policy issue, however, Clinton's approach represented a significant improvement over the policies of Reagan and Bush. Clinton embraced full funding of the Ryan White CARE Act. He created the National Task Force on AIDS Drug Development, whose goal was to examine how drugs could be released more quickly. Clinton's Department of Justice took action to address discrimination against people who were either HIV-positive or diagnosed with AIDS. In June 1993, the Clinton administration announced that rules governing the ability of people infected with HIV to claim disability benefits would be relaxed considerably. Finally, Clinton's 1992 election meant that more federal money was allocated for AIDS research. For example, in fiscal year 1994, funding for AIDS research increased by 18 percent.
The AIDS issue maintained a low profile in the 1996 presidential elections, although some saw electoral motivation in the Clinton administration's decision to extend Medicaid coverage to include protease inhibitors. Shortly after Clinton's reelection, he outlined a six-point AIDS strategy for his second term. This strategy included the development of a cure and a vaccine, a reduction in new HIV infections, guaranteed care and services for those with HIV, opposition of AIDS-related discrimination, support for international efforts, and effective practical application of advances in scientific knowledge.
Although Clinton was far more attentive to AIDS than his predecessors, many AIDS activists still felt that he and his administration were not doing all that could be done in the face of AIDS, especially given candidate Clinton's promises during the 1992 campaign. Underlying this critique is an assumption that has pervaded the discussion of AIDS since its inception in 1981 -- that, of all the participants in the American political scene, the president is best situated to educate the public and to provide moral and political leadership in the face of a public health disaster.
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The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith, Editor. Copyright Â© 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers.
Encyclopedia of AIDS $25 US/832 pp/Illustrated